Provider Demographics
NPI:1902021447
Name:WESTERN MAINE MULTI MEDICAL SPECIALIST
Entity Type:Organization
Organization Name:WESTERN MAINE MULTI MEDICAL SPECIALIST
Other - Org Name:WESTERN MAINE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP- FISCAL
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-743-9292
Mailing Address - Street 1:301 US ROUTE ONE
Mailing Address - Street 2:BUILDING C
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:193 MAIN ST
Practice Address - Street 2:SUITE 9
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5645
Practice Address - Country:US
Practice Address - Phone:207-743-8766
Practice Address - Fax:207-743-1579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME127080000Medicaid